Fundamentals of Nursing Unit 2 – Flashcards

Systematic and dynamic triproblem-solving method by which nurses individualize holistic care for each client. The five steps of the nursing process: Assessment-assess patient to determine the need for nursing care, make judgement about health status, and ability to manage his or her own healthcare; collect, validate, and communicate patient data; data includes:nursing history, physical assessment, review of patient record and nursing literature, consult with patient's support people and other health care professionals. Diagnosis- analysis of patient data to identify patient strengths and health problems that nurses can resolve with a prioritized list of nursing diagnoses; interpret and analyze data, identify strengths and problems, formulate and validate diagnoses, prioritize them. Planning/outcome ID- specification of outcomes to prevent, reduce, or resolve problem; individualized plan of nursing care; establish priorities, write comes and develop evaluative strategy, select nursing interventions, and communicate plan Implementation-carry out plan of care, continue data collection, modify as needed, & document care Evaluation- measure how well patient has achieved outcomes, ID factors that contribute to success or failure, modify as need

Systematic problem-solving process that involves 1. Problem Identification. 2. Data collection. 3. Hypothesis formulation. 4. Plan of Action. 5. Hypothesis testing. 6. Interpretation of Results, and 7. Evaluation resulting in conclusion or revision of the study.

thinking that does not blindly accept arguments and conclusions. Rather, it examines assumptions, discerns hidden values, evaluates evidence, and assesses conclusions. 4 domains Element of thought: purpose, problem, point of view is flexible, empirical evidence, clear, relevant, and deep concept and ideas, sound assumptions, implication and consequences known Abilities: to evaluate sources, analyze, clarify, use new insights, generate and assess solutions, develop criteria for evaluation, read, write, speak, and listen critically Affective dimensions: think independently, fairly, avoid bias and judgement, have intellectual courage, integrity, reason, perseverance, and curiosity Intellectual standards: clear, specific, relevant, consistent, deep

CTIs - evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice.

Provides a visual framework for organizing conceptual information in the process of defining a word or concept. The framework contains the category, properties, and examples of the word or concept.

assessment of the patient by interview to identify the patient's health status, strengths, health problems, health risks, and need for nursing care

initial is comprehensive upon admission, focused is done when a problem has already been identified, ER is done when an physiological or psychological crisis presents to ID life threatening problems

An assessment that is scheduled to compare a patient's current status to baseline data obtained earlier

a standard established by healthcare institutions that specifies the information that must be collected from every patient

the reasoning involved in drawing a conclusion or making a logical judgment on the basis of circumstantial evidence and prior conclusions rather than on the basis of direct observation

Analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve.

certain physiologic complications that nurses monitor to detect onset or changes in status. ex. potential complication: hypoglycemia

erroneously labeling selected patient patterns as unhealthy

is a grouping of patient data or cues that points to the existence of a patient health problem

actual represents a problem validated by major defining characteristics and has 4 components label, definition, characteristics, and related factor risk diagnoses are clinical judgements that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation possible are statements describing suspected problem for which data is needed

health promotion, nutrition, elimination and exchange, activity/rest, perception/cognition, self perception, role relationships, sexuality, life principals, safety/protection, comfort, & growth/development

Clinical judgment and an individual, family or community in transition from a specific level of wellness to a higher level of wellness.

cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation; ex Rape trauma syndrome

identify diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness

standardized multidisciplinary plans for a specific diagnosis or procedure that identify specific aspects of care to be performed during a designated length of stay

measurable criteria that indicates whether a person has achieved the expected benefit of nursing care

is an expected conclusion to a patient health problem, or in the event of a wellness diagnosis, an expected conclusion to a patient's health expectation.

(NOC) a taxonomy for describing client outcomes that respond to nursing interventionso 330+ outcomes in 7 domains (e.g., physiologic health or family health) and a class within the domain (e.g., nutrition under physiologic health or family well-being under family health) o Each outcome assigned a 4-digit identifier and a definition o Similar to a "goal" in traditional language o Provides standardized language so that data on individual clients can be entered into computer databases that are analyzed and used in nursing practice

the trade name for a method that makes use of a series of cards to concisely organize and record client data and instructions for daily nursing care--especially care that changes frequently and must be kept up-to-date

(NIC) first comprehensive, validated list of nursing interventions applicable to all settings that can be used by nurses in multiple specialties and facilitates the work of identifying appropriate interventions

independent nursing actions that involve carrying out nurse-prescribed interventions written on the nursing plan of care, as well as any other actions that nurses initiate without the direction or supervision of another healthcare professional and that result from their assessment of patient needs

any treatments, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes

written plans that detail the nursing activities to be executed in specific situations

empower the nurse to initiate actions that ordinarily require the order or supervision of a physician examples include admission for ob/gyn patients, protocols for bowel programs, standard orders for overdose, and pain management that enable nurse to select strength

dependent nursing actions, involve carrying out physician-prescribed order.

commitment to healthier patients, quality care, reduced costs, and making a difference; accomplished by discovering a problem, planning a strategy, implementing a change, and assessing the change to see if the goal is met

A review by persons with similar professional qualifications.

A criteria that identifies, measures, monitors, and evaluates patient care is

(audit) focuses on the environment in which care is provided

evaluation focusing on the nature and sequence of activities carried out by nurses implementing the nursing process

focuses on demonstrable changes in the client's health status as result of nursing care

method of evaluating the outcomes of nursing care or the process by which these outcomes are achieved using a review of patient records

the evaluation of nursing care and patient outcomes while the patient is receiving care, conducted by using direct observation of nursing care, patient interviews, and chart review to determine whether the specified evaluative criteria are met

evaluation of nursing care and patient outcomes after the patient has been discharged using postdischarge questionnaires, patient interviews, or chart review to collect data

documentation system in which each healthcare group records data on its own separate form

Notes used in the patient chart to track the progress and condition of the patient.

descriptive record of the patient's condition; includes patient's response to interventions by health professionals and patient's progress toward goal achievement

specific health problem -system of documentation that includes the database problem list , plan. and progress notes.

method of charting narrative progress notes; organizes data according to subjective information (S), objective information (O), assessment (A), and plan (P)

documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem (P), intervention (I), evaluation (E) format, and evaluated each shift

intended to focus on client. 3 columns (time/date, focus, progress notes) Progress Notes column organized by (D) data, (A) action, and (R) response. Used in conjucntion with flowsheets and checklists. + provides holistic perspective

the only thing that is documented is abnormal assessment findings and nursing care that deviates from written standards. No normal findings or routine care is charted.

case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions

documentation method in case management that records unexpected events, the cause for the event, actions taken in response to the event, and discharge planning when appropriate

An electronic record of health-related information on an individual that can be created, gathered, managed, & consulted by authorized clinicians & staff within ONE healthcare organization

An electronic record of health-related information on an individual that conforms to nationally interoperability standards & that can be created, managed, & consulted by authorized clinicians & staff across MORE THAN ONE healthcare organization, created by self with software template

record routine aspects of nursing

records measurements and observations made daily, every shift or 3-4x a day eg weight, Dr visits, BP temp

Part of a patient's medical record. It is a comprehensive outline of the patient's entire hospital stay. It includes condition at time of admission, admitting diagnosis, test results, treatments and patient's response, final diagnosis, and follow-up plans.

component of medicare's partnership with the home care industry; group of data elements that represent core items of a comprehensive assessment for an adult home care patient, and forms the basis for measuring patient outcomes

consistent, clear, structured, and easy-to-use method of communication between healthcare personnel; it organizes communication by the categories of: Situation, Background, Assessment, and Recommendations.

a record completed after an unusal occurrence that describes what happened and the steps taken after the occurence.

nursing specialty integrating nursing science, computer science, and information science in identifying, collecting, processing, and managing information to support nursing practice, administration, education, research, and the expansion of knowledge.

one hallmark of professional nursing relationships, need to be distinguished from aggressive...the key is open, honest , and direct communication with "I" statements....(1) having empathy (2) describing one's feelings or the situation (3) clarifying expectations (4) anticipating consequences

relation of mutual understanding or trust and agreement between people

term used in communication theory to specify the one who prepares and sends a message to the receiver/decoder

communication with oneself

practitioners move their hands a few inches from a patient's body, purportedly "pushing energy fields into balance"

anger and aggressive behavior between nurses or nurse-to-nurse hostility